Terry Pannkuk, DDS, MScD – Instructional, Complications: Advanced Management, Fractured Roots, Recall Observations
Should you completely trough a crown-root fracture out?
Patient: 62 year-old female with arthritis
Chief Complaint: constant tooth pain especially when biting
Dental History: The patient had a gold crown placed on the mandibular right first molar (tooth #30) within a year of being referred to the author. Pain reported at an 8/10 level had developed 5 days prior to the endodontic referral.
6 comments
Michaelson, P. A Novel Treatment for Propagated Crown Fractures. J Endod 2015;41:130-134 posed a similar approach to managing crown fractures. In this submitted case I recommend fine microburs and ultrasonics to limit the width of the crack preparation.
What do you hope the Biodentine does for the tooth in the "fracture prep" vs. other restorative materials? Do you have more confidence in a bonded core vs. amalgam when there is occlusal metal?
This is my current evaluation of materials to use for filling of the crack "microprep" which may change depending upon future outcome results and new evidence: Bioceramic (Endosequence sealer, lowest viscosity form): best for narrow discrete micropreps where flow is critical. Excellent flow and excellent biologic properties (i.e fibroblast adhesion). Uniquely suitable for most cases with intact minimally restored crowns Biodentine has better strength physical properties than MTA. Resin materials (with the exception of Geristore) have unfavorable biologic reactions (inhibition of fibroblasts/lack of adhesion on a cellular level). The crack was not deep so Biodentine was chosen. If it was deep requiring a lower viscosity filling material I would have chosen EndoSequence sealer. Composite resins (including flowables): not suitable due to unfavorable fibroblast adhesion properties as in some of these cases the prep may extend near or to the PDL. Resin modified glass ionomers (Geristore, other brands have not been shown to be as predictable, Al-Sabek et al, and Dragoo studies): Excellent if flow is not required, more suitable for wider preps on teeth with more compromised tooth structure. Biodentine seems to have slightly better flow and sealing properties though. MTA: tends to wash out with less favorable flow and doesn't bond, not particularly suitable for filling of crack micropreps. This is my current clinical rationale based upon my own interpretation of the best-fit available evidence.
Regarding the second question- filling the access cavity prep with an amalgam versus a bonded resin: Amalgam has superior compressive strength properties compared to a bonded resin. A resin bond will tend to hydrolyze and fail under long term cyclic loading. One has to balance esthetic versus functional considerations. If the tooth is in the "esthetic zone' then cosmetics take precedence over minor functional considerations. When esthetics are not a consideration, materials and techniques should be chosen to idealize function and longevity. Rick Schwartz wrote an excellent review of the literature on the topic on the Journal of Endodontics (2005). Here's the link: http://www.jendodon.com/article/S0099-2399%2805%2960134-3/abstract
How does fibroblast adhesion benefit us in a crack "microprep"? Is the goal to allow PDL fibroblasts to infiltrate the fracture and adhere to the material to provide a "lateral seal"? Microscopically, would we see PDL in the fracture if the material "does its job". Sorry for so many questions!
Very good question. There are numerous considerations and I'm not sure we've determined the ideal material. In many of these cases the micro-prep may come very close to communicating with the PDL, if it does, fibroblast adhesion is important to maintain external attachment and prevent development of a periodontal pocket. Depending upon the depth of the crack, external extension of the crack, the proposed function of the tooth, the presence of staining/caries, and other factors, the following characteristics of a repair material are important: 1. low viscosity 2. disinfection/caries resistance 3. sealing potential 4. physical strength/integrity 5. Biocompatibility/Potential to regain attachment should the prep extend to the periodontium